Provider Demographics
NPI:1922140805
Name:JOHNSON, BARBRA RAYE (OD)
Entity Type:Individual
Prefix:DR
First Name:BARBRA
Middle Name:RAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11611 GLEN RD.
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854
Mailing Address - Country:US
Mailing Address - Phone:301-983-9697
Mailing Address - Fax:301-983-9697
Practice Address - Street 1:5268 NICHOLSON LN STE D
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1010
Practice Address - Country:US
Practice Address - Phone:301-881-6232
Practice Address - Fax:301-881-6234
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTAO824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415747500Medicaid
MD636SMedicare PIN